JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

Kaiser Foundation Hospital and Rehab Center

2 / 5

At a glance

Kaiser Foundation Hospital and Rehab Center carries a 2-star CMS overall rating — below the national norm. On healthcare-associated infection measures, it performs better than the national average on 12 and worse on 0.

Healthcare-Associated Infections

lower is better · 36 measures reported

Rates of infections patients can acquire while receiving care, such as central-line and catheter-associated infections, MRSA, and C. difficile.

MeasureScoreCompared to national
Central Line Associated Bloodstream Infection (ICU + select Wards): Lower Confidence Limit0.375Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit2.267Same as national
Central Line Associated Bloodstream Infection: Number of Device Days4814Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases4.888Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases5Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards)1.023Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit—Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit0.603Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days4069Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases4.968Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases0Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards)0.000Better than national
SSI - Colon Surgery: Lower Confidence Limit0.852Same as national
SSI - Colon Surgery: Upper Confidence Limit3.853Same as national
SSI - Colon Surgery: Number of Procedures137Same as national
SSI - Colon Surgery: Predicted Cases3.594Same as national
SSI - Colon Surgery: Observed Cases7Same as national
SSI - Colon Surgery1.948Same as national
SSI - Abdominal Hysterectomy: Lower Confidence Limit—Not available
SSI - Abdominal Hysterectomy: Upper Confidence Limit—Not available
SSI - Abdominal Hysterectomy: Number of Procedures15Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.134Not available
SSI - Abdominal Hysterectomy: Observed Cases1Not available
SSI - Abdominal Hysterectomy—Not available
MRSA Bacteremia: Lower Confidence Limit0.019Same as national
MRSA Bacteremia: Upper Confidence Limit1.921Same as national
MRSA Bacteremia: Patient Days46578Same as national
MRSA Bacteremia: Predicted Cases2.568Same as national
MRSA Bacteremia: Observed Cases1Same as national
MRSA Bacteremia0.389Same as national
Clostridium Difficile (C.Diff): Lower Confidence Limit0.251Better than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.751Better than national
Clostridium Difficile (C.Diff): Patient Days44020Better than national
Clostridium Difficile (C.Diff): Predicted Cases28.863Better than national
Clostridium Difficile (C.Diff): Observed Cases13Better than national
Clostridium Difficile (C.Diff)0.450Better than national

Complications & Deaths

lower is better · 20 measures reported

Rates of serious complications (like hip/knee replacement problems or accidental cuts during surgery) and 30-day mortality rates for common conditions.

MeasureScoreCompared to nationalSample
Rate of complications for hip/knee replacement patients—Not available—
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate4.3Same as national188
Death rate for heart attack patients—Not available—
Death rate for CABG surgery patients—Not available—
Death rate for COPD patients—Not available—
Death rate for heart failure patients14.9Same as national29
Death rate for pneumonia patients19.1Same as national30
Death rate for stroke patients—Not available—
Pressure ulcer rate0.41Same as national842
Death rate among surgical inpatients with serious treatable complications—Not available—
Iatrogenic pneumothorax rate0.20Same as national941
In-hospital fall-associated fracture rate0.26Same as national954
Postoperative hemorrhage or hematoma rate2.22Same as national163
Postoperative acute kidney injury requiring dialysis rate—Not available—
Postoperative respiratory failure rate8.91Same as national26
Perioperative pulmonary embolism or deep vein thrombosis rate4.20Same as national167
Postoperative sepsis rate—Not available—
Postoperative wound dehiscence rate1.75Same as national39
Abdominopelvic accidental puncture or laceration rate1.00Same as national176
CMS Medicare PSI 90: Patient safety and adverse events composite0.97Same as national—

Unplanned Hospital Visits & Readmissions

lower is better · 14 measures reported

How often patients return to the hospital unexpectedly within 30 days of discharge — a marker of care quality and discharge planning.

MeasureScoreCompared to nationalSample
Hospital return days for heart attack patients—Not available—
Hospital return days for heart failure patients—Not available—
Hospital return days for pneumonia patients18.4Not available26
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)14.6Same as national260
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)—Not available—
Rate of inpatient admissions for patients receiving outpatient chemotherapy—Not available—
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy—Not available—
Ratio of unplanned hospital visits after hospital outpatient surgery—Not available—
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate—Not available—
Rate of readmission for CABG—Not available—
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients—Not available—
Heart failure (HF) 30-Day Readmission Rate—Not available—
Rate of readmission after hip/knee replacement—Not available—
Pneumonia (PN) 30-Day Readmission Rate15.9Same as national26

Patient Experience (HCAHPS)

higher is better · 9 measures reported

What patients say about their hospital stay — communication with nurses and doctors, responsiveness, cleanliness, pain management, and whether they would recommend the hospital.

MeasureScoreSample
Nurse communication - star rating31056
Doctor communication - star rating41056
Communication about medicines - star rating31056
Discharge information - star rating41056
Cleanliness - star rating31056
Quietness - star rating31056
Overall hospital rating - star rating41056
Recommend hospital - star rating41056
Summary star rating41056

Timely & Effective Care

higher is better (unless a wait time) · 30 measures reported

How consistently hospitals follow recommended care processes — for example, giving heart-attack patients aspirin on arrival, or the average time spent in the emergency department.

MeasureScoreSample
Emergency department volume——
Global Malnutrition Composite Score——
Global Malnutrition Composite Score: Malnutrition Diagnosis Documented——
Global Malnutrition Composite Score: Malnutrition Risk Screening——
Global Malnutrition Composite Score: Nutrition Assessment——
Global Malnutrition Composite Score: Nutritional Care Plan——
Hospital Harm - Severe Hyperglycemia712534
Hospital Harm - Severe Hypoglycemia22369
Hospital Harm - Opioid Related Adverse Events——
Healthcare workers given influenza vaccination465142
Average (median) time all patients spent in the emergency department before leaving from the visit, including psychiatric/mental health patients and patients who were transferred to another facility. A lower number of minutes is better——
Average (median) time patients spent in the emergency department before leaving from the visit, excluding patients transferred to another facility or psychiatric care/mental health patients. A lower number of minutes is better——
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better——
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better——
Left before being seen——
Head CT results——
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients——
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery——
ST-Segment Elevation Myocardial Infarction (STEMI)——
Safe Use of Opioids - Concurrent Prescribing81622
Appropriate care for severe sepsis and septic shock70158
Septic Shock 3-Hour Bundle7356
Septic Shock 6-Hour Bundle8131
Severe Sepsis 3-Hour Bundle90158
Severe Sepsis 6-Hour Bundle94108
Discharged on Antithrombotic Therapy9199
Anticoagulation Therapy for Atrial Fibrillation/Flutter——
Antithrombotic Therapy by End of Hospital Day 2——
Venous Thromboembolism Prophylaxis——
Intensive Care Unit Venous Thromboembolism Prophylaxis——

Maternal Health

lower is better · 4 measures reported

Measures of maternal outcomes and safe delivery practices, including severe complications during childbirth.

MeasureScoreSample
Cesarean Birth——
Risk Adjusted Severe Obstetric Complications (All)——
Risk Adjusted Severe Obstetric Complications (excluding blood-transfusion-only cases)——
Maternal Morbidity Structural MeasureYes—

Frequently asked questions

How is Kaiser Foundation Hospital and Rehab Center rated?
Kaiser Foundation Hospital and Rehab Center has a 2 out of 5 CMS overall star rating as of the latest CMS release.
Does Kaiser Foundation Hospital and Rehab Center have emergency services?
According to CMS records, Kaiser Foundation Hospital and Rehab Center does not report a 24/7 emergency department.
Where is Kaiser Foundation Hospital and Rehab Center located?
Kaiser Foundation Hospital and Rehab Center is located at 975 Sereno Dr, Vallejo, CA 94589.
What type of hospital is Kaiser Foundation Hospital and Rehab Center?
Kaiser Foundation Hospital and Rehab Center is classified by CMS as a Acute Care Hospitals facility (Voluntary non-profit - Private).

Data as of 2026-06-14. Source: CMS Provider Data Catalog. This is public data provided for informational purposes only and is not medical advice. See our methodology and editorial policy.

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